Emergency Childbirth: Unassisted Birth Protocol

Recognizing Active Labor

Stages of Labor

First stage: Regular contractions, cervix dilates from 0 to 10cm. Early first stage: contractions every 5-15 minutes, manageable. Active first stage: contractions every 2-4 minutes, intense, lasting 45-60 seconds. Transition (8-10cm): most intense, contractions nearly continuous.

Second stage: From 10cm dilation through delivery of the baby. The urge to push becomes overwhelming.

Third stage: Delivery of the placenta. Normally within 30 minutes after baby delivery.

Is this real labor or false labor?

• Real labor: contractions become progressively closer, longer, and stronger with time. Do not subside with rest or position changes.
• False labor (Braxton Hicks): contractions may be regular briefly, then stop or become irregular. Subside with rest.

Signs That Delivery Is Imminent

• Contractions every 2-3 minutes or less
• The mother says "I need to push" — take this seriously. The urge to push is involuntary and intense.
• Visible bulging of the perineum during contractions
• Baby's presenting part (usually the head) visible at the vaginal opening

Setting Up

Clean the environment as best possible. You cannot achieve sterility, but you can minimize contamination.

• Clean your hands thoroughly (soap and water, then hand sanitizer)
• Clean towels or sheets for the mother to lie on and to wrap the baby
• Clean dry towels to dry and warm the baby immediately after delivery
• Gloves if available
• Clean cord clamps or clean shoelaces/strips of cloth for tying the cord
• Scissors or knife (sterilized by boiling or alcohol) for cutting the cord after it stops pulsing
• A bulb syringe for clearing the airway if available
• Warm blankets for both mother and baby

Position the mother: Semi-reclining (back against pillows at 45 degrees) or on hands and knees (reduces perineal tearing in many studies). Lying flat on the back is the least preferred position but acceptable in an emergency.

The Delivery: Second Stage

Let the Body Lead

The single most important principle: do not interfere unless there is a specific complication. The uterus knows what it is doing. Your role is to support, not to pull.

Do not pull the baby. Traction on the head during delivery causes brachial plexus injury (shoulder damage causing permanent arm weakness). The baby is delivered by uterine contraction force — your hands guide and support, they do not pull.

Head Delivery

1. Crowning: The head becomes visible with each contraction and recedes between contractions. This is normal. It may take many contractions before the head remains visible between contractions.

2. Perineal support: Place a clean towel against the perineum (the tissue between the vaginal opening and rectum). Apply gentle counterpressure during contractions — this slows the head's descent slightly, reducing the risk of perineal tearing.

3. "Crown and pant": When the head is fully crowning (widest diameter at the vaginal opening), ask the mother to stop pushing and breathe through contractions with quick short breaths. This controlled delivery of the head reduces tearing.

4. Head delivery: The head typically delivers in a face-down position, then rotates to face sideways as the shoulders prepare to deliver. This rotation is the baby's body adjusting to the pelvic anatomy. Do not try to prevent or force this rotation.

5. Check for nuchal cord: As soon as the head is out, run your finger around the baby's neck to feel for the umbilical cord. If the cord is loose, slip it over the head. If tight, clamp in two places and cut before the body delivers.

6. Clear the airway if needed: Most babies do not need aggressive airway suctioning — the pressure of delivery squeezes fluid from the airway. If the baby's face appears covered in thick meconium (dark green-black fluid), try to clear the mouth and nose before the baby takes a breath. Use a bulb syringe if available: squeeze the bulb, insert gently into the nose or mouth, release to suction.

Shoulder and Body Delivery

7. Shoulders: After the head rotates, the shoulders typically deliver with the next contraction. The anterior shoulder (facing the mother's front) delivers first. Support the head with both hands, guide gently downward as the mother pushes to deliver the upper shoulder, then upward to deliver the lower shoulder. This is guiding, not pulling.

8. Body: The rest of the body follows quickly. Support the slippery baby with both hands — have a towel ready. Babies are slippery.

9. Note the time of birth.

Immediate Newborn Care

The First 30 Seconds

1. Hold the baby on the mother's abdomen or at the level of the uterus while the cord is still attached. Do not raise the baby above the uterus (causes blood to flow back from baby to placenta).

2. Dry and stimulate: Vigorously dry the baby with a clean towel. Stimulation of the trunk and extremities helps initiate breathing. The drying and stimulation together accomplish this.

3. Assess breathing: Most babies begin breathing and crying within 30-60 seconds. A baby that does not cry by 30 seconds needs stimulation — rub the back and flick the soles of the feet.

4. Keep warm: Cover the baby immediately. Newborns lose heat rapidly. The mother's skin-to-skin contact is the best warmer.

Cord Management

Delayed cord clamping: Leave the cord intact for at least 1-3 minutes after birth. The cord continues to pulse (delivering blood to the baby from the placenta) for several minutes. Clamping early reduces the baby's blood volume. After the cord stops pulsing (usually 1-3 minutes), clamp in two places — 2cm and 5cm from the baby's abdomen — and cut between the clamps.

Cord ties: Clean shoelaces, strips of boiled cloth, or commercial clamps. Tie firmly enough to prevent bleeding.

Apgar Assessment (1 Minute and 5 Minutes)

Score 0, 1, or 2 for each item:

| Category | 0 | 1 | 2 | |---|---|---|---| | Appearance (color) | Blue all over | Blue extremities, pink trunk | Pink all over | | Pulse | None | Below 100/min | Above 100/min | | Grimace (reflex) | None | Grimace | Cry, cough | | Activity (muscle tone) | None/floppy | Some flexion | Active motion | | Respiration | None | Weak, irregular | Strong cry |

Score 7-10: Normal. Score 4-6: Moderate concern, stimulate and reassess. Score 0-3: Severe, begin newborn CPR.

Third Stage: Placenta Delivery

Do not pull on the cord to deliver the placenta. Cord traction can cause uterine inversion — a medical emergency where the uterus turns inside out.

Allow the placenta to deliver naturally. Signs of placenta separation: a small gush of blood from the vagina, the cord appears to lengthen, the uterus becomes firmer and rises. This typically occurs within 5-30 minutes.

When the placenta separates, gentle cord traction with one hand supporting the uterus abdominally (to prevent inversion) can assist the final delivery. The mother can bear down gently.

After placenta delivery:

• Inspect it: it should be complete. Missing pieces remain in the uterus and cause bleeding and infection.
• Begin uterine massage: with one hand above the pubic bone stabilizing the uterus, use the other hand to massage the fundus (top of the uterus, felt abdominally as a firm ball) in a circular motion. This causes uterine contraction and reduces bleeding.
• Encourage the mother to nurse the baby immediately: breastfeeding triggers oxytocin release, which causes uterine contraction and reduces postpartum hemorrhage risk.

Recognizing and Managing Complications

Shoulder Dystocia

After the head delivers, the shoulder becomes stuck behind the pubic bone. Signs: the head delivers normally but does not rotate, or the baby's face shows a "turtle sign" (head retracted back toward the vaginal opening after delivery).

McRoberts maneuver:

1. Have the mother pull her knees to her chest and flex the hips maximally (hyperflex — knees touching the chest)
2. Apply suprapubic pressure: have an assistant press firmly just above the pubic bone in a downward direction (not fundal pressure)
3. These two maneuvers together widen the pelvic outlet and dislodge the shoulder in most cases

If McRoberts fails: deliver the posterior arm — insert your hand into the vagina, find the baby's posterior arm, and deliver it. This rotates the baby and frees the stuck shoulder.

Postpartum Hemorrhage

See the dedicated postpartum hemorrhage guide for full protocol. Rapid response is essential — a woman can exsanguinate in 15-20 minutes from uterine atony.

Non-Breathing Newborn

Dry and stimulate vigorously. If no response at 30 seconds:

• Reposition the airway: head in neutral position, chin slightly lifted
• Begin rescue breathing: 30 breaths per minute, covering both mouth and nose
• If no pulse: add chest compressions (see infant CPR guide)
• Two fingers on center of chest, compress 1.5 inches, at 120 compressions per minute
• 3:1 ratio of compressions to breaths for newborn

Transfer and Evacuation

Mother should be evaluated at a hospital as soon as possible after emergency field delivery, even if the delivery appeared uncomplicated. Assess for:

• Retained placenta fragments
• Perineal laceration requiring repair
• Blood loss assessment
• Newborn evaluation (bilirubin, weight, temperature, feeding)